Multimedia tools are effective for the acquisition of cognitive skills in colorectal surgery and are well accepted as an educational resource.

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The operative treatment of ulcerative colitis has changed with the development of the stapled technique of pouch construction and the procedure of double-stapled ileal pouch-anal anastomosis (IPAA). This technique is being used at many specialist centres as the procedure of choice for restorative proctocolectomy (RPC) for ulcerative colitis because of its many advantages, including a shorter operating time, a comparatively easier technique owing to the omission of the mucosectomy, a lower rate of pelvic sepsis and also some evidence that the reduced anal manipulation and preservation of the anal transitional zone mucosa lead to a better functional outcome. However, the major theoretical disadvantage of this technique is the possible development of dysplasia and eventually carcinoma in the retained mucosa. The aim of this study was to evaluate this risk of dysplasia in the retained anal mucosa in patients with ulcerative colitis who underwent RPC with a double-stapled IPAA without mucosectomy. Patients and methodsThe records of 109 patients who underwent RPC with nonmucosectomy double-stapled IPAA for ulcerative colitis from September 1988 to December 1993 were reviewed. A minimum follow-up of 1 year was obtained. Patients who had IPAA for any condition other than ulcerative colitis were excluded, as were those with ulcerative colitis who were found to have carcinoma or dysplasia in the colon at the time of surgery. The histology of the distal rectal doughnut as well as the follow-up biopsies were reviewed by one of two pathologists. Follow-up studies included clinical evaluation with digital examination, endoscopy and random 2-mm pinch biopsies of the retained mucosal cuff. These biopsies were undertaken at the time of ileostomy closure and then annually, and any dysplasia was noted and graded. If the doughnut and two consecutive biopsies revealed squamous epithelium, further follow-up biopsies were not performed. ResultsThere were 69 men (mean age 42.5 (range 14-72) years) and 40 women (mean age 3 7 5 (range 23-71)years). A total of 109 rectal doughnuts were reviewed. During follow-up of 1-6 (mean 2.6) years, a total of 186 biopsies of the anal mucosa were examined (mean 1.7 follow-up biopsies per patient; all patients had at least one biopsy). Only one patient was noted to have low-grade dysplasia in the distal rectal doughnut at the time of operation. Four 1406 follow-up biopsies of the retained mucosa in this patient over a period of 3 years, however, revealed no evidence of dysplasia. There was no recorded case of dysplasia in the follow-up biopsies of the retained mucosa in any patient in the series. No carcinomas were noted, either at the time of surgery or during the follow-up period. DiscussionDouble-stapled IPAA has become the procedure of choice in patients with ulcerative colitis after RPC. Ambroze et al. ' have questioned the advisability of nonmucosectomy ileoanal reservoir because of the potential for malignant change in the retained mucosa. However, there have been no reports of carcinoma in the ...

Background This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery. Methods This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score‐matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score‐matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery. Results A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score‐matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498). Conclusion There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast‐induced nephropathy should not be used as a reason to avoid contrast‐enhanced CT.

The peri-operative use of angiotensin-converting enzyme inhibitors or angiotensin-2 receptor blockers is thought to be associated with an increased risk of postoperative acute kidney injury. To reduce this risk, these agents are commonly withheld during the peri-operative period. This study aimed to investigate if withholding angiotensin-converting enzyme inhibitors or angiotensin-2 receptor blockers peri-operatively reduces the risk of acute kidney injury following major non-cardiac surgery. Patients undergoing elective major surgery on the gastrointestinal tract and/or the liver were eligible for inclusion in this prospective study. The primary outcome was the development of acute kidney injury within seven days of operation. Adjusted multi-level models were used to account for centre-level effects and propensity score matching was used to reduce the effects of selection bias between treatment groups. A total of 949 patients were included from 160 centres across the UK and Republic of Ireland. From this population, 573 (60.4%) patients had their angiotensin-converting enzyme inhibitors or angiotensin-2 receptor blockers withheld during the peri-operative period. One hundred and seventy-five (18.4%) patients developed acute kidney injury; there was no difference in the incidence of acute kidney injury between patients who had their angiotensin-converting enzyme inhibitors or angiotensin-2 receptor blockers continued or withheld (107 (18.7%) vs. 68 (18.1%), respectively; p = 0.914). Following propensity matching, withholding angiotensin-converting enzyme inhibitors or angiotensin-2 receptor blockers did not demonstrate a protective effect against the development of postoperative acute kidney injury (OR (95%CI) 0.89 (0.58-1.34); p = 0.567).